2. INTRODUCTION
• C shaped canals are an uncommon variation, which can pose a challenge to even the experienced
clinician during root canal negotiation.
• first described by Cooke and Cox.1979,
• most commonly found in mandibular second molar,
• a ribbon shaped canal that includes the mesiobuccal and distal canals and sometimes the
mesiolingual canal.
• Sometimes instead of having several discrete orifices, the pulp chamber of C shaped canal is a
single ribbon shaped orifice with a 180 arc, which in mandibular molars starts at the mesiolingual
line angle and sweeps around the buccal to the end at the distal aspect of the pulp chamber.
• complexity of C shaped canal prevents these canals from being cleaned, shaped and obturated
effectively during the root canal therapy.
• Very little dentin separates the external surface from the C shaped canal system, there by
increasing the possibility of stripping perforation during endodontic or restorative treatment.
• So a proper identification of this abnormal root pattern will help in successful management.
3. ETIOLOGY
• Failure of the Hertwig’s epithelial root sheath to fuse on the lingual or
buccal root surface .
• also formed by coalescence because of deposition of cementum with
time.
4. ANATOMICAL FEATURES
• C shaped canal appears when fusion of either the buccal or lingual aspect
of the mesial and distal root
• C configuration, which is an important anatomic variation, presents a thin
fin connecting the mesial and distal individual canal which makes the canal
cross-section C shaped and presents much difficulty in its through cleaning
and shaping and subsequent obturation.
• Recognition of a C shaped canal configuration before treatment will surely
facilitate of more effective management.
• This fusion remains irregular, and the two roots stays connected by inter
radicular ribbon of dentin.
• floor of pulp chamber is deep and has an unusual anatomic appearance.
• Two or three canals may be found in the C shaped groove or the C shape
may be continuous through out the root length.
5. CLASSIFICATION
1) Melton’s classification Based on the cross sectional shape
• Category 1-continuous C shaped canal running from the pulp chamber to the apex defines a C shaped
outline without any separation.
• Category 2- the semicolon ( ; )shaped orifice in which dentine separates a main C shaped canal from one
mesial distinct canal.
• Category 3- refers to those with two or more discrete and separate canals
2) Fans classifications
• Category 1 (C1) - the shape was an interrupted C with no separation or division.
• Category 2 (C2) - the canal shape resembled a semicolon resulting from a discontinuation of the C outline,
but either angle alpha or beta angle should be no less than 60 degree. (Figure 4)
• Category 3- 2 or 3 separate canals and both angle, alpha and beta were less than 60 degree. (Figure 5)
3) Fans classification ( Radiographic classification)
• Type 1- conical or square root with a vague, radiolucent longitudinal line separating the root into distal and
mesial parts. There was a mesial and distal canal that merged into one before exiting at the apical foramen
6. • Type 2 - conical or square root with a vague, radiolucent longitudinal line separating the root into distal and
mesial parts. There was a mesial and distal canal and the two canals appeared to continue on their own
pathway to the apex.
• Type 3 – conical or square root with a vague, radiolucent longitudinal line separating the root into distal and
mesial parts. There was a mesial and distal canal, one canal curved to and superimposed on this radiolucent
line when running towards the apex, and the other canal appeared to continue on its own pathway to the
apex.
4) Classification based on DSR images and micro CT reconstruction Digital subtraction radiography (DSR), which
eliminates the identical image regions in a series of radiographs obtained in the same exposures position and
at different time intervals. Radiographic contrast medium is often used in clinic to change the radio opacity of
some anatomic structures before the DSR. Micro CT scans have been applied not only to evaluate canal shapes
or cross-section of teeth. All the DSR images and buccolingual reconstructed canal images based on micro CT
scanning were classified
• Type1-(Merging type) - canal images merged into one major canal before exiting from the apical foramen.
• Type2 (Symmetrical type) –There were separate mesial and distal canal appeared to be symmetrical in their
size and continued on their own pathway to the apex.
• Type3 (Asymmetrical type)-There were separate mesial and distal canals and mesial and the distal canals
7. • appeared to be symmetrical in their size and continued on their own
pathway to the apex, the distal canal seems much wider than the
mesial canal.
• Diagnosis All the teeth that qualified as having a C shaped canal
system had to exhibit all the following 3 features;
1) Fused roots.
2) A longitudinal groove on the lingual and buccal surface of the root.
3) At least one cross-sectional of the canal belongs to the C1, C2 or C3
configuration.
8.
9. RADIOGRAPHIC DIAGNOSIS
• A preoperative radiograph and additional radiographs from 20 degree mesial or
distal projection may be the only noninvasive means clinically to provide clues
about the canal morphology.
• radicular fusion or proximity, a large distal canal, a narrow mesial canal and a
blurred image of a third canal in between. (Figure 8)
• Radiographic interpretation is overall effective when based on film combinations
e.g. preoperative and working length radiographs) or preoperative and final
radiographs and or all 3 radiographs.
• radiographs taken while negotiating the canals may reveal two characteristics for
such canal configuration-instruments tend to converge at the apex (Figure 9)
and/or may exit at the furcation. (Figure 10).
• latter sometimes resembles a perforation of furcation.
• Micro CT has been used not only to assess cross-section of teeth, but also for
three dimensional reconstructions of canals at high resolution.
10.
11. CLINICAL DIAGNOSIS
• 1) Anatomical outline of the floor of the pulp chamber
• 2) Persistence of hemorrhage
• 3) Pain when separate canal orifice were found Fused roots and C
shaped roots may present with narrow root grooves that predispose
to localized periodontal disease, which may be the first diagnostic
indication of such anatomic variation.
• When a deep groove is present on the lingual and buccal surface of a
root a C shaped canal is expected.
12. MANAGEMENT
Importance of preoperative radiograph
• shows limited information.
• Apically tapering roots and roots that appear to be continuous or
square at the apex can be suspected as C shaped canal configuration.
• Some C shaped canals are difficult to interpret because of the
thickness of the bony trabeculae.
• C shaped must be suspected when the roots are fused or close to
each other.
• It should be noted that bilateral occurrence is possible
13. ACCESS CAVITY PREPARATION
• Initial canal system recognition occurs after achievement of routine
endodontic access and removal of tissue from the pulp chamber.
• Fiber optic Tran illumination can enhance the variant canal anatomy
identification.
• Placing the fiber optic tip under the rubber dam on the buccal
surface illuminates the pulp chamber.
• The canal system appears as a dark line in an illuminated area.
• Deep orifice preparation and careful probing with small files will help
in assessing the types of C shaped canal. (Figure 11 & Figure 12)
14. Cleaning and shaping
• In all categories mesiobuccal and distal canal are prepared normally.
• Isthmus should not be prepared larger than 25 size files, otherwise strip
perforation can occur.
• Extravagant use of small sized file and 5.25% sodium hypochlorite is the key to
through debridement in the narrow canal isthmus.
• An increased volume of irrigant and deeper penetration of with small instruments
using sonic and ultrasonic may allow for cleansability in fan shaped areas of the C
shaped canal.
• Aggressive instrumentation may sometimes cause perforation.
• The ribbon canal space is frequently eccentric to the lingual side of the C shaped
radicular dentin.
• An anticurvature filing method in the coronal third of the canal is needed to
prevent perforation.
15. OBTURATION
• mesiolingual canal and the distal canal can be prepared and obturated as standard
canals.
• Application of thermoplastisized gutta percha is more appropriate technique of
obturation.
• Gutta-percha can be thermo plasticized with a heated spreader in an open flame,
electric spreader or injectible (Obtura) systems.
• Proper placement of the sealer with ultrasonic endodontic files is critical. Endotech 2 can
also be used with a zap and tap maneuver; i.e., preheating the Endotech plugger for 4-5
sec before insertion (zap) and then moving the hot instrument in and out in short
continuous strokes (taps) 10 to 15 times.
• The plugger was removed while still hot, followed by a cold spreader with insertion of
additional accessory points.
• Touch n heat system can also be used. (Figure 13 & Figure 14)
•
16. ENDODONTIC SURGERY
• intracanal communications or fins visualized on serial sections reinforce the difficulty the clinician would
encounter after apicectomy with retropreparation and eventual retrofilling.
• If endodontic surgical intervention is indicated for a molar with a C shaped root canal anatomy, strong
consideration should be given to extraction, retrofilling and intensional replantation.
•
17. RESTORATION AND PROGNOSIS
• If post placement for a crown core is desired use of only distal canal (if present independently) should be
considered.
• When sound principle of biomechanical preparation and obturation and restoration are followed, the long
term prognosis of C shaped canal root retention equals that of other molars.
